Highlights

of the 2019 Focused Updates

to the American Heart Association
Guidelines for Cardiopulmonary
Resuscitation and Emergency
Cardiovascular Care -
Heart & Stroke Foundation
of Canada Edition
The American Heart Association and
Heart & Stroke thanks the following people
for their contributions to the development of
this publication: Ashish R. Panchal, MD, PhD;
Jonathan P. Duff, MD, MEd; Marilyn B. Escobedo,
MD; Jeffrey L. Pellegrino, PhD, MPH; Nathan
Charlton, MD; Mary Fran Hazinski, RN, MSN; the
AHA Adult, Pediatric, and Neonatal Guidelines
Focused Updates writing groups; the American
Heart Association and American Red Cross First
Aid Guidelines Focused Update writing group; and
the AHA Guidelines Focused Updates Highlights
Project Team. Heart & Stroke would like to thank the
Canadian volunteers who participate as members of
these groups for their contribution to these writing
groups and the impact their work has for Canada.

Heart & Stroke is the guidelines-setting body for

Canada. It is one of the founding members of the
International Liaison Committee on Resuscitation
(ILCOR), which reviews evidence and science relating
to resuscitation. Heart & Stroke’s job, as a member
of ILCOR, is to bring together and support Canadian
subject matter experts who join experts from around
the globe in this review process. ILCOR’s consensus on
science culminates in recommendations published by
member-organizations that guide resuscitation practice
and training. In the spirit of collaboration, the AHA and
Heart & Stroke work together to ensure resuscitation
guidelines are applicable to the Canadian audience.
These Highlights summarize the key issues addressed in the 2019 focused updates to the American Heart Association (AHA)
Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). They have been developed for
resuscitation providers and for AHA and Heart & Stroke instructors to focus on evidence reviewed and guidelines recommenda-
tions that are based on the most recent evidence evaluations sponsored by the International Liaison Committee on Resuscitation
(ILCOR). In addition, they provide the rationale for the recommendations.

Process Overview for Developing

Guidelines Focused Updates
The 2019 focused updates to the AHA Guidelines for CPR and ECC are based on ILCOR’s international continuous evidence
evaluation process, which involves hundreds of international resuscitation scientists and experts who evaluate, discuss, and debate
thousands of peer-reviewed publications. In this process, ILCOR task forces prioritize topics for review with input from resuscitation
councils, including the AHA and Heart & Stroke. Once a topic is approved for evaluation, a systematic review is commissioned and
performed by a knowledge synthesis unit or a systematic reviewer, with input from ILCOR content experts. After the systematic
review is complete, the ILCOR task forces review the evidence and develop a draft Consensus on Science With Treatment
Recommendations (CoSTR) that is posted online for public comment (see the ILCOR website for all draft CoSTRs). Between
November 12, 2018, and March 20, 2019, 6 ILCOR task forces posted draft CoSTRs on the following 12 topics:

Basic Life Support Task Force

Emergency Care: Dispatcher Instruction in CPR
https://costr.ilcor.org/document/emergency-care-dispatcher-instruction-in-cpr


Advanced Life Support Task Force

Advanced Airway Management During Adult Cardiac Arrest
https://costr.ilcor.org/document/advanced-airway-management-during-adult-cardiac-arrest
Vasopressors in Adult Cardiac Arrest
https://costr.ilcor.org/document/vasopressors-in-adult-cardiac-arrest
Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest—Adults
https://costr.ilcor.org/document/extracorporeal-cardiopulmonary-resuscitation-ecpr-for-cardiac-arrest-adults

Pediatric Task Force

Dispatcher Instruction in CPR—Pediatrics
https://costr.ilcor.org/document/dispatcher-instruction-in-cpr-pediatrics
Advanced Airway Interventions in Pediatric Cardiac Arrest
https://costr.ilcor.org/document/advanced-airway-interventions-in-pediatric-cardiac-arrest
Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest—Pediatrics
https://costr.ilcor.org/document/extracorporeal-cardiopulmonary-resuscitation-ecpr-for-cardiac-arrest-pediatrics
Pediatric Targeted Temperature Management Post–Cardiac Arrest
https://costr.ilcor.org/document/pediatric-targeted-temperature-management-post-cardiac-arrest

Neonatal Life Support Task Force

Initial Oxygen Concentration for Preterm Neonatal Resuscitation
https://costr.ilcor.org/document/initial-oxygen-concentration-for-preterm-neonatal-resuscitation
Initial Oxygen Concentration for Term Neonatal Resuscitation
https://costr.ilcor.org/document/initial-oxygen-concentration-for-term-neonatal-resuscitation

Education, Implementation, and Teams and Basic Life Support Task Forces
Cardiac Arrest Centres vs Noncardiac Arrest Centres—Adults
https://costr.ilcor.org/document/cardiac-arrest-centers-versus-non-cardiac-arrest-centers-adults

First Aid Task Force

First Aid Interventions for Presyncope
https://costr.ilcor.org/document/first-aid-interventions-for-presyncope

Heart & Stroke Edition 2

Public feedback, including hundreds of comments from more than 23 000 views of the draft CoSTRs, contributed to the develop-
ment of the final CoSTRs that the ILCOR task forces included in the 2019 International Consensus on CPR and ECC Science With
Treatment Recommendations summary. This summary was published simultaneously in Circulation and Resuscitation (refer to the
Recommended Reading list at the end of these Highlights).
The AHA guidelines writing groups, which include Canadian volunteers, reviewed all of the evidence identified by the ILCOR
systematic reviews and carefully considered the ILCOR CoSTRs when they created the 2019 focused updates, published in
Circulation in November 2019. The summary of the sequence of production and unique content for each ILCOR and AHA
document is illustrated in Figure 1.

Figure 1. Sequence and process for the development of the focused updates to the AHA Guidelines for CPR and ECC with the use of
the ILCOR systematic review and ILCOR task force CoSTR.

Knowledge synthesis unit or systematic reviewer (with participation of

ILCOR content experts) completes a systematic review and develops
the manuscript for journal publication. This review includes
• GRADE bias assessment tables and terminology
• Forest plots
• No treatment recommendations

ILCOR task forces discuss and debate the evidence and develop an
online draft CoSTR for posting on the ILCOR website, containing
• No GRADE tables or forest plots (reference the systematic review)
• Sections
-- Introduction that includes a brief description of the evidence
evaluation process
-- Population, Intervention, Comparator, Outcome, Study Designs,
and Time Frame
-- Consensus on science with treatment recommendations
-- GRADE wording used for certainty of evidence for interventions and
for strength (strong vs weak) of recommendation
-- Values and preferences
-- Evidence-to-decision tables
-- Knowledge gaps

ILCOR task force writing groups develop a CoSTR summary for

journal publication simultaneously in Circulation and Resuscitation. The
final wording is approved by all ILCOR member resuscitation councils.
This document contains
• No GRADE tables, no forest plots, and no evidence-to-decision tables
• Final wording of consensus on science
• Final treatment recommendations
• More detail about task force insights on values and preferences

Resuscitation councils such as the AHA develop council-specific

guidelines and any necessary training materials consistent with the
ILCOR CoSTR but appropriate to council resources, training, and
structure of the healthcare system.

Abbreviations: AHA, American Heart Association; CoSTR, Consensus on Science With Treatment Recommendations;
GRADE, Grading of Recommendations, Assessment, Development, and Evaluation; ILCOR, International Liaison
Committee on Resuscitation.
Heart & Stroke Edition 3
These AHA and Heart & Stroke focused updates serve to update specific parts of the 2010 Guidelines, the 2015 Guidelines
Update, and the 2017 and 2018 focused updates. Copies of these previously released guidelines and updates are available online
at heartandstroke.ca/get-involved/learn-cpr, and a complete update of the AHA and Heart & Stroke Guidelines for CPR and ECC is
planned for 2020.
As in previous years, the 2019 focused updates use the AHA/American College of Cardiology recommendation system and
taxonomy for class of recommendation and level of evidence (Table 1). Because these Highlights are designed as a summary,
they do not cite the supporting published studies and do not list the associated classes of recommendation or levels of evidence.
Readers are strongly encouraged to visit the Heart & Stroke Guidelines page to read the 2019 focused updates and to visit the
ILCOR CoSTR website for further details.
Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing
in Patient Care (Update August 2015)*

CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

CLASS 1 (STRONG) Benefit >>> Risk LEVEL A

Suggested phrases for writing recommendations: • High-quality evidence‡ from more than 1 RCT
• Is recommended
• Is indicated/useful/effective/beneficial • Meta-analyses of high-quality RCTs
• Should be performed/administered/other
• Comparative-Effectiveness Phrases†:
• One or more RCTs corroborated by high-quality registry studies
–– Treatment/strategy A is recommended/indicated in preference to
treatment B
LEVEL B-R (Randomized)
–– Treatment A should be chosen over treatment B • Moderate-quality evidence‡ from 1 or more RCTs

CLASS 2a (MODERATE) Benefit >> Risk • Meta-analyses of moderate-quality RCTs

Suggested phrases for writing recommendations:
• Is reasonable LEVEL B-NR (Nonrandomized)
• Can be useful/effective/beneficial
• Moderate-quality evidence‡ from 1 or more well-designed, well-
• Comparative-Effectiveness Phrases†:
executed nonrandomized studies, observational studies, or registry
–– Treatment/strategy A is probably recommended/indicated in
studies
preference to treatment B

• Meta-analyses of such studies

–– It is reasonable to choose treatment A over treatment B

LEVEL C-LD (Limited Data)

CLASS 2b (WEAK) Benefit ≥ Risk
• Randomized or nonrandomized observational or registry studies with
Suggested phrases for writing recommendations:
limitations of design or execution
• May/might be reasonable

• Meta-analyses of such studies

• May/might be considered

• Physiological or mechanistic studies in human subjects

• Usefulness/effectiveness is unknown/unclear/uncertain or not well-
established
LEVEL C-EO (Expert Opinion)
CLASS 3: No Benefit (MODERATE) Benefit = Risk • Consensus of expert opinion based on clinical experience
(Generally, LOE A or B use only)

Suggested phrases for writing recommendations:
• Is not recommended
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other
Class 3: Harm (STRONG) Risk > Benefit
Suggested phrases for writing recommendations:
• Potentially harmful
• Causes harm
• Associated with excess morbidity/mortality
• Should not be performed/administered/other
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many
important clinical questions addressed in guidelines do not lend themselves to clinical
trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
particular test or therapy is useful or effective.
* The outcome or result of the intervention should be specified (an improved clinical
outcome or increased diagnostic accuracy or incremental prognostic information).
† For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only),
studies that support the use of comparator verbs should involve direct comparisons
of the treatments or strategies being evaluated.
‡ The method of assessing quality is evolving, including the application of stan-
dardized, widely-used, and preferably validated evidence grading tools; and for
systematic reviews, the incorporation of an Evidence Review Committee.
COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.

Heart & Stroke Edition 4

Highlights of the 2019 Focused Updates
to the AHA Guidelines for CPR and ECC
—Heart & Stroke Edition
The 2019 focused updates to the AHA
Guidelines for CPR and ECC include
revisions to the following parts of the
2015 Guidelines Update:
Part 4: Systems of Care and
Continuous Quality Improvement:
dispatcher-assisted CPR (DA-CPR) for
adults and the potential role of cardiac
arrest centres (CACs)
Part 7: Adult Advanced Cardiovascular
Life Support: use of advanced airways,
vasopressors, and extracorporeal
CPR (ECPR) during resuscitation. Note
that the ECPR content also serves to
update a section with the same name
in Part 6: Alternative Techniques and
Ancillary Devices for Cardiopulmonary
Resuscitation.
Part 11: Pediatric Basic Life Support
and Cardiopulmonary Resuscitation
Quality: DA-CPR in infants and children
Part 12: Pediatric Advanced Life
Support: use of advanced airway
interventions in pediatric cardiac
arrest, ECPR for in-hospital cardiac
arrest (IHCA), and post–cardiac arrest
targeted temperature management
(TTM)
Part 13: Neonatal Resuscitation: initial
oxygen concentration for term and
late-preterm newborns (35 weeks of
gestation or more) and initial oxygen
concentration for preterm newborns
(less than 35 weeks of gestation)
The 2019 American Heart Association
and American Red Cross focused
update to the first aid guidelines
includes a new set of interventions
for the following:
Part 15: First Aid: 2015 American
Heart Association and American Red
Cross Guidelines Update for First Aid:
presyncope
Part 4: Systems of
Care and Continuous
Quality Improvement
The AHA Adult writing group reviewed
evidence and recommendations for the
following topics in 2019:
Dispatcher-assisted CPR: DA-
CPR has been integrated into many
emergency medical services (EMS)
systems of care across the nation and
is viewed as an important link between
the community of bystanders and EMS
care. In this update, the writing group
addressed the question of whether the
provision of DA-CPR is associated with
improved outcomes from adult out-of-
hospital cardiac arrest (OHCA).
Cardiac arrest centres: CACs
are specialized centres that provide
contemporary and comprehensive
evidence-based resuscitation and
post–cardiac arrest care. This review
addressed whether transport of
patients with OHCA to a specialized
CAC, compared with treatment at an
undesignated centre, improves patient
outcomes.
Dispatcher-Assisted CPR
There are a variety of terms to describe
the process that a dispatcher uses to
provide real-time CPR instructions to
bystanders who are at the scene of an
OHCA. For consistency, in this review,
the term dispatcher-assisted CPR
is used to describe such coaching.
However, other terms, such as telecom-
municator CPR and telephone CPR,
could be substituted.
The provision of DA-CPR is thought
to increase the rates of bystander
CPR for victims of OHCA and thereby
improve outcomes. Since 2015, a
number of published studies have
evaluated the use of DA-CPR for
adult OHCA. This review examined
the effectiveness of DA-CPR through
multiple perspectives and assessed its
association with outcomes from OHCA.
2019 (Updated): We recommend that
emergency dispatch centres offer CPR
instructions and empower dispatchers
to provide such instructions for adult
patients in cardiac arrest.
2019 (Updated): Dispatchers should
instruct callers to initiate CPR for adults
with suspected out-of-hospital cardiac
arrest.
2017 (Old): We recommend that when
dispatchers’ instructions are needed,
dispatchers should provide chest
compression–only CPR instructions to
callers for adults with suspected OHCA.
2015 (Old): Dispatchers should instruct
callers to perform CPR in cases of
suspected cardiac arrest. Dispatchers
should provide chest compression–only
CPR instructions to callers for adults
with suspected OHCA.
Why: Although clear outcome benefits
from DA-CPR were not demonstrated
in all reviewed studies, this change
in the AHA guidelines reflects the
preponderance of the existing evidence,
involving tens of thousands of patients
from a number of countries. These
outcomes indicated an association
between DA-CPR and improved clinical
outcomes after OHCA. Furthermore,
the association of DA-CPR with a more
than 5-fold likelihood of bystander CPR
led to the conclusion that the overall
benefit from DA-CPR merits a strong
endorsement.
Heart & Stroke Edition 5
 This review did not evaluate the
effects of the type of CPR instruction
given by the dispatchers. As a result, the
2015 recommendation for dispatchers
to provide chest compression–only CPR
instructions to callers for adults with
suspected OHCA remains unchanged.
Cardiac Arrest Centres
CACs are specialized centres where
post–cardiac arrest care—at a
minimum—includes emergent cardiac
catheterization, TTM, and multimodal
prognostication. Although there are a
variety of terms to define these centres
(eg, cardiac arrest receiving centres,
comprehensive cardiac centres, cardiac
resuscitation centres), for consistency
in these guidelines, the term cardiac
arrest centres is used. The benefit of a
regional system of care model has been
successful in improving outcomes in
other time-critical diseases (eg, trauma,
ST-segment elevation myocardial infarc-
tion, stroke) in which comprehensive
management is not possible at all in-
stitutions. This topic was prioritized for
review to determine if similar benefit is
imparted to victims of OHCA through
the use of CACs.
2019 (Updated): A regionalized
approach to post–cardiac arrest care
that includes transport of resuscitated
patients directly to specialized cardiac
arrest centres is reasonable when
comprehensive post–cardiac arrest care
is not available at local facilities.
2015 (Old): A regionalized approach to
OHCA resuscitation that includes the
use of cardiac resuscitation centres may
be considered.
Why: Evidence-based, comprehensive
post–cardiac arrest care, including
the availability of emergent cardiac
catheterization, TTM, hemodynamic
support, and neurologic expertise is
critically important for resuscitated
victims of cardiac arrest. These
interventions may represent a logical
clinical link between successful
resuscitation (ie, return of spontaneous
circulation [ROSC]) and ultimate
survival. When a suitable complement
of post–cardiac arrest services is not
available locally, direct transport of
the resuscitated patient to a regional
centre offering such support may be
beneficial and is a reasonable approach
to ongoing care, when it is feasible
and possible to accomplish in a timely
manner.
Part 7: Adult Advanced
Cardiovascular Life Support
The AHA Adult writing group consid-
ered the following key issues and major
changes for the 2019 focused update to
the adult advanced cardiovascular life
support (ACLS) guidelines:
Use of advanced airways during
CPR: Providers frequently place
advanced airway devices during CPR
to support adequate ventilation and
reduce the risk of pulmonary aspiration
of orogastric secretions. This update
addressed the use of 3 possible
airway management strategies during
resuscitation: bag-mask ventilation,
supraglottic airway placement, and
endotracheal intubation strategies.
Use of vasopressors: The goal of
pharmacotherapy for cardiac arrest is to
facilitate restoration and maintenance of
a perfusing spontaneous rhythm. This
2019 focused update addresses the use
of the vasopressors epinephrine and
vasopressin during cardiac arrest.
Role of extracorporeal membrane
oxygenation (ECMO) in CPR:
ECMO may be used as rescue therapy
during CPR; this use is then termed
extracorporeal CPR. The writing group
examined the studies that reported
outcome of ECPR for IHCA.
Use of Advanced Airways
During CPR
To use advanced airways effectively,
healthcare providers must maintain their
knowledge and skills through frequent
practice. Airway management during
cardiac arrest usually starts with a basic
strategy, such as bag-mask ventilation,
and it may progress to an advanced
airway strategy (eg, supraglottic airway
placement or endotracheal intubation
strategy). Since 2015, a number of ran-
domized controlled trials (RCTs) have
provided new information on the use
and choice of airway strategies during
resuscitation for OHCA. These included
comparing bag-mask ventilation to
an endotracheal intubation strategy
and supraglottic airway strategy to
an endotracheal placement strategy.
Refer to Figure 2 for a schematic rep-
resentation of the following 6 updated
recommendations:
2019 (Updated): Either bag-mask
ventilation or an advanced airway
strategy may be considered during CPR
for adult cardiac arrest in any setting.
2019 (Updated): If an advanced
airway is used, the supraglottic airway
can be used for adults with out-of-
hospital cardiac arrest in settings with
low tracheal intubation success rate
or minimal training opportunities for
endotracheal tube placement.
2019 (Updated): If an advanced airway
is used, either the supraglottic airway
or endotracheal tube can be used for
adults with out-of-hospital cardiac arrest
in settings with high tracheal intubation
success rates or optimal training
opportunities for endotracheal tube
placement.
2019 (Updated): If an advanced
airway is used in the in-hospital setting
by expert providers trained in these
procedures, either the supraglottic
airway or endotracheal tube can
be used.
2019 (Updated): Frequent experience
or frequent retraining is recommended
for providers who perform endotracheal
intubation.
2019 (Updated): Emergency medical
services systems that perform
prehospital intubation should provide
a program of ongoing quality
improvement to minimize complications
and to track overall supraglottic airway
and endotracheal tube placement
success rates.
2010 and 2015 (Old): Either a bag-
mask device or an advanced airway may
be used for oxygenation and ventilation
during CPR in both IHCA and OHCA.
For healthcare providers trained in their
use, either a supraglottic airway device
Heart & Stroke Edition 6
Figure 2. Schematic representation of ACLS recommendations for use of advanced airways during CPR.

Abbreviations: ACLS, advanced cardiovascular life support; CPR, cardiopulmonary resuscitation; EMS, emergency
medical services.
*Frequent experience or frequent retraining is recommended for providers who perform endotracheal intubation.

Heart & Stroke Edition 7

or an endotracheal tube may be used
as the initial advanced airway during
CPR. Frequent experience or frequent
retraining is recommended for providers
who perform endotracheal intubation.
EMS systems that perform prehospital
intubation should provide a program
of ongoing quality improvement to
minimize complications.
Why: Recommendations for advanced
airway placement during cardiac arrest
presume that the provider has the initial
training and skills as well as the ongoing
experience to insert the airway and
verify proper position while minimizing
interruption in chest compressions.
The choice of bag-mask ventilation vs
advanced airway insertion, then, will be
determined by the skill and experience
of the provider and the patient needs.
Frequent experience and training are
an important aspect of maintaining
high overall success rates for airway
management and should be part of
ongoing quality improvement. As a
result, an informed decision on the
choice of an airway strategy for OHCA
cannot be made without tracking airway
management success rates. From these
data, informed decisions on airway
strategy choices can be made for
patients with OHCA.
Use of Vasopressors During CPR
The writing group reviewed the pub­
lished evidence on the use of the
standard epinephrine dose, standard-
vs high-dose epinephrine, vasopressin
vs epinephrine, vasopressin plus epi-
nephrine compared with epinephrine
alone, and the timing of epinephrine
administration. The writing group
focused only on the use of vasopressors
for cardiac arrest and did not review
vasopressor use before or after
cardiac arrest.
Standard-Dose Epinephrine
The writing group reviewed the
published evidence about the effec-
tiveness of the standard dose (1 mg) of
epinephrine, as reported in 2 RCTs, as
well as a pooled subgroup analysis of
outcomes based on patient presenting
rhythm. Only one of the RCTs looked
at long-term outcome, and the small
number of survivors in that study limits
the certainty of any conclusions based
on the results.
2019 (Updated): We recommend
that epinephrine be administered to
patients in cardiac arrest. On the basis
of the protocol used in clinical trials, it is
reasonable to administer 1 mg every 3
to 5 minutes.
2015 (Old): Standard-dose epinephrine
(1 mg every 3 to 5 minutes) may be
reasonable for patients in cardiac arrest.
Why: Randomized controlled studies
have demonstrated that the use of
epinephrine is associated with improved
30-day survival and survival to hospital
discharge as well as the short-term
outcomes of ROSC and survival to
hospital admission. These results also
suggested a possible benefit in favorable
neurologic outcome, particularly for
patients with initial nonshockable
rhythm. Epinephrine was not shown to
increase rates of survival with favorable
neurologic outcome, and one evaluation
demonstrated an increase in short-term
survivors with unfavorable neurologic
outcome. However, the significant
improvement in ROSC, short-term and
long-term survival, and potential for
good neurologic outcome (especially for
those with initial nonshockable rhythm)
support a strong recommendation for
epinephrine, despite some remaining
uncertainty about the overall impact on
neurologic outcome.
Standard Dose Epinephrine
vs High-Dose Epinephrine
In the 2010 ACLS guidelines, high-dose
epinephrine was not recommended
except in special circumstances, such
as β-blocker overdose, or when titrated
to monitored parameters. In 2015, the
use of high-dose epinephrine was not
recommended because it was not
thought to be beneficial (Class 3: No
Benefit). Although there were no new
studies of high-dose epinephrine iden-
tified since 2015, the evidence of the
effects of standard-dose vs high-dose
epinephrine was reanalyzed for the
2019 focused update as part of the
comprehensive review of the use of
vasopressors for the treatment of
cardiac arrest.
2019 (Unchanged): High-dose
epinephrine is not recommended for
routine use in cardiac arrest.
2015 (Old): High-dose epinephrine is
not recommended for routine use in
cardiac arrest.
Why: Since 2015, no new studies were
identified through a systematic search,
so the 2015 recommendation remains
unchanged.
Vasopressin vs Epinephrine
The results of 3 RCTs were evaluated
in a meta-analysis, and the writing
group considered an additional study to
evaluate the effects of initial vasopres-
sin vs initial epinephrine on outcomes
from cardiac arrest. The studies were all
considered to be of low certainty, and all
had small sample sizes.
2019 (Updated): Vasopressin may
be considered in a cardiac arrest but
offers no advantage as a substitute for
epinephrine in cardiac arrest.
2015 (Old): Vasopressin offers
no advantage as a substitute for
epinephrine in cardiac arrest.
Why: The RCTs comparing initial
vasopressin to initial epinephrine failed
to show any outcome benefit from the
use of vasopressin compared with
epinephrine. In addition, epinephrine has
been shown to improve survival when
compared with placebo, while there has
been no similar placebo-controlled trial
of vasopressin. Because there is also
no evidence that vasopressin is superior
to epinephrine, the writing group
agreed that it is appropriate to use only
epinephrine during cardiac arrest to
maintain simplicity in the cardiac
arrest treatment algorithm and in the
drugs required.
Epinephrine in Combination
With Vasopressin
vs Epinephrine Only
The writing group analyzed the results
of 3 small RCTs that compared the use
of initial epinephrine plus vasopres-
sin with initial epinephrine only during
resuscitation.
Heart & Stroke Edition 8
 Although immediate
bystander CPR improves
survival from cardiac arrest,
too few victims of OHCA
receive bystander CPR...
The likelihood of bystander
CPR nearly tripled if DA-CPR
was offered to callers.
2019 (Updated): Vasopressin in
combination with epinephrine may be
considered during cardiac arrest but
offers no advantage as a substitute for
epinephrine alone.
2015 (Old): Vasopressin in combination
with epinephrine offers no advantage
as a substitute for standard-dose
epinephrine in cardiac arrest.
Why: The RCTs comparing the
combination of vasopressin and
epinephrine with epinephrine alone
did not demonstrate a beneficial effect
from the addition of vasopressin to
epinephrine. Although the RCTs involved
only a small number of patients, the
writing group agreed that the use of
epinephrine alone as a vasopressor
during cardiac arrest would maintain
simplicity in the cardiac arrest treatment
algorithm and minimize the number of
different drugs required for the treatment
of cardiac arrest.
Timing of Administration
of Epinephrine
The writing group analyzed data from
16 observational studies, including 10
that compared early vs late epinephrine
administration. There were signifi-
cant differences in the studies, which
precluded use of meta-analysis, and
multiple variables may have affected the
outcomes of the studies.
2019 (Updated): With respect to timing,
for cardiac arrest with a nonshockable
rhythm, it is reasonable to administer
epinephrine as soon as feasible.
2019 (Updated): With respect to timing,
for cardiac arrest with a shockable
rhythm, it may be reasonable to
administer epinephrine after initial
defibrillation attempts have failed.
2015 (Old): It may be reasonable to
administer epinephrine as soon as
feasible after the onset of cardiac arrest
due to an initial nonshockable rhythm.
Why: No RCTs have directly investigated
the effect of the timing of epinephrine
administration on outcomes from
cardiac arrest. Available data from
the 16 observational studies used a
variety of definitions of early epinephrine
administration. However, all studies
demonstrated higher rates of ROSC in
association with early administration
of epinephrine. The lack of other
competing beneficial interventions
for cardiac arrest with nonshockable
rhythms as well as higher rates of
ROSC and survival with epinephrine
use for these arrests provided the
basis for recommending epinephrine
administration as soon as feasible for
arrest with nonshockable rhythms.
For cardiac arrest with shockable
rhythms, the provision of high-quality
CPR and defibrillation should be the
immediate care priorities, with the use
of epinephrine and antiarrhythmics for
shock-resistant ventricular fibrillation/
pulseless ventricular tachycardia cardiac
arrest (Box).
Extracorporeal CPR
ECPR refers to the initiation of cardiopul-
monary bypass during the resuscitation
of a patient in cardiac arrest, with the
goal of supporting end-organ perfusion
while potentially reversible conditions are
addressed. ECPR is a complex interven-
tion that requires a highly trained team,
specialized equipment, and
multidisciplinary support within a health-
care system (Figure 3).
The writing group analyzed the data
from 15 observational studies that
differed in study design, definitions of
outcomes, and patient selection.
2019 (New): There is insufficient
evidence to recommend the routine use
of extracorporeal CPR for patients with
cardiac arrest.
2019 (Updated): Extracorporeal
CPR may be considered for selected
patients as rescue therapy when
conventional CPR efforts are failing in
settings in which it can be expeditiously
implemented and supported by skilled
providers.
2015 (Old): There is insufficient
evidence to recommend the routine
use of ECPR for patients with cardiac
arrest. In settings where it can be rapidly
implemented, ECPR may be considered
for select patients for whom the
suspected etiology of the cardiac arrest
is potentially reversible during a limited
period of mechanical cardiorespiratory
support.
Why: Currently, there are no published
RCTs evaluating the use of ECPR for
OHCA or IHCA. However, a number of
observational studies suggest improved
survival with good neurologic outcome
when ECPR is used for select patient
populations. While there is currently
no evidence to clearly identify the ideal
patients to select, most of the studies
analyzed in the systematic review
included relatively young patients with
few comorbidities. Data are needed to
address patient selection as well as to
evaluate the cost-effectiveness of this
therapy, the consequences of resource
allocation, and the ethical issues
surrounding the use of ECPR as a mode
of resuscitation therapy.
Heart & Stroke Edition 9
Box. Timing and sequence of drug administration during cardiac arrest—the knowns and unknowns.

There is insufficient evidence to identify the optimal timing of epinephrine and antiarrhythmic drug delivery during
cardiac arrest. As a result, the recommended sequence of resuscitation including drug delivery depicted in the
AHA ACLS Adult Cardiac Arrest Algorithm and guidelines has been determined by expert consensus. The following
includes the considerations that contributed to the development of the consensus recommendations.

Epinephrine for Cardiac Arrest With Nonshockable Rhythm (PEA/Asystole)

For nonshockable rhythms, the AHA and Heart & Stroke recommends providing high-quality CPR and administering
epinephrine as soon as feasible. The rationale is based on the need to optimize CPP, because an ischemic ventricle
without a spontaneous rhythm is likely to remain in this condition unless coronary (myocardial) perfusion improves.
The α-adrenergic (vasoconstrictive) effects of epinephrine help to improve CPP. At this time, there is little else to offer
those with nonshockable rhythms other than high-quality CPR and epinephrine and a search for and treatment of re-
versible causes.

Epinephrine for Cardiac Arrest With Shockable Rhythm (VF or pVT)

For shockable rhythms, the initial priority is providing high-quality CPR plus delivering a shock as soon as possible.
This may result in elimination of VF and resumption of an organized and then a perfusing rhythm, even before drugs
are administered. Epinephrine administration is depicted in the VF/pVT pathway of the ACLS Adult Cardiac Arrest
Algorithm after the second shock; at this point, it is likely that administration of epinephrine may improve CPP suffi-
ciently to improve myocardial energetics, enabling a subsequent (third) shock, if needed, to terminate the VF/pVT. All
resuscitation councils (worldwide) recommend at least 1 shock (and most recommend several shocks) before admin-
istering epinephrine.
The AHA and Heart & Stroke do not recommend epinephrine administration before the first shock because CPR
plus the shock alone may result in elimination of VF/pVT and resumption of an organized and ultimately perfusing
rhythm. The AHA and Heart & Stroke do not recommend epinephrine administration immediately after the first shock
(ie, during the 2 minutes of CPR after the first shock) because providers won’t know if VF/pVT has been eliminated.
If the first shock was successful (ie, eliminates VF/pVT), a bolus of epinephrine may provoke recurrence of VF/pVT
(or other arrhythmias) and can increase oxygen demand just when resumption of spontaneous rhythm is occurring.
On the other hand, if VF/pVT persists at the next rhythm check (ie, after delivery of the first shock plus 2 minutes of
high-quality CPR), the AHA and Heart & Stroke recommend a second shock, with immediate resumption of CPR and
administration of epinephrine. The rationale is that, by this time the myocardium is likely to be ischemic, so even if the
second shock terminates VF/pVT, the epinephrine and high-quality CPR may improve CPP and myocardial perfusion
and will potentially enable the heart to resume and maintain a spontaneous, perfusing rhythm. On the other hand,
if the second shock did not eliminate the VF/pVT, the epinephrine and high-quality CPR may help improve CPP and
increase the likelihood that the third shock will be successful.

Antiarrhythmic and Epinephrine Administration for Cardiac Arrest

With Shockable Rhythm (VF or pVT)
There is no evidence to determine if an antiarrhythmic agent is best given before or after epinephrine, or even
when the antiarrhythmic should be administered; such a decision may depend on the acute circumstances.
Experienced providers may tailor the sequence of drug delivery to individual patient needs. For example, patients
with recurring episodes of VF may derive greater benefit from the rhythm-stabilizing effects of an antiarrhythmic drug
like amiodarone or lidocaine than from epinephrine (which may even be proarrhythmic under such circumstanc-
es). Conversely, persistent VF may require improving CPP before any other drug will be adequately delivered to the
heart via the coronary arteries. That is, epinephrine plus high-quality CPR might improve coronary and myocardial
perfusion and increase the likelihood of successful rhythm conversion when amiodarone or lidocaine is given.
More evidence is needed in the form of prospective randomized studies to identify optimal timing of drug
administration in cardiac arrest.

Abbreviations: ACLS, advanced cardiovascular life support; AHA, American Heart Association; CPP, coronary
perfusion pressure; CPR, cardiopulmonary resuscitation; PEA, pulseless electrical activity; pVT, pulseless ventricular
tachycardia; VF, ventricular fibrillation.

Heart & Stroke Edition 10

Figure 3. Schematic depiction of components of ECMO circuit as used for ECPR. Components include venous cannula, a pump, an
oxygenator, and arterial cannula.
Abbreviations: ECMO, extracorporeal membrane oxygenation; ECPR, extracorporeal cardiopulmonary resuscitation.
Part 11: Pediatric
Basic Life Support
and Cardiopulmonary
Resuscitation Quality
In 2019, the AHA Pediatric writing group
reviewed the outcomes associated with
the use of DA-CPR in pediatric OHCA.
The evidence and recommendations for
pediatric DA-CPR differ somewhat from
the recommendations for DA-CPR and
adult victims of OHCA. However, as in
the adult population, DA-CPR is associ-
ated with increased bystander CPR rates
and improved outcomes for infants and
children with OHCA.
DA-CPR for Pediatric OHCA
Although immediate bystander CPR
improves survival from cardiac arrest, too
few victims of OHCA receive bystander
CPR. The writing group reviewed the
evidence of outcomes associated with
DA-CPR for pediatric OHCA based
on registry data from EMS systems in
Korea and Japan. Note that the review
did not include evaluation of the specific
protocols or language used by the dis-
patchers to support bystander CPR.
2019 (New): We recommend that
emergency medical dispatch centres
offer dispatcher-assisted CPR
instructions for presumed pediatric
cardiac arrest.
2019 (New): We recommend that
emergency dispatchers provide CPR
instructions or pediatric cardiac arrest
when no bystander CPR is in progress.
2019 (New): There is insufficient
evidence to make a recommendation
for or against dispatcher-assisted
CPR instructions for pediatric cardiac
arrest when bystander CPR is already
in progress.
Previous: There is no previous
recommendation on this topic.
Why: DA-CPR is associated with
increased survival in children with
OHCA. The likelihood of bystander CPR
nearly tripled if DA-CPR was offered to
callers, and 30-day survival improved.
Bystander CPR—with or without
dispatcher assistance—was associated
with improved survival with favorable
neurologic outcome at 1 month.
Part 12: Pediatric
Advanced Life Support
The AHA Pediatric writing group identi-
fied and analyzed new evidence about
the use of advanced airways during CPR,
ECMO resuscitation (ie, ECPR), and TTM
after resuscitation from cardiac arrest
in infants and children. Analysis of this
evidence resulted in refinement of existing
recommendations about the use of these
therapies.
Advanced airways: Most pediatric
cardiac arrests are triggered by a
deterioration of respiratory function.
Bag-mask ventilation can be a
reasonable alternative to an advanced
airway (such as endotracheal intubation
or a supraglottic airway).
Heart & Stroke Edition 11
ECPR: The rapid deployment of
venoarterial ECMO during active CPR
(ECPR) or for patients with intermittent
ROSC may be considered in pediatric
patients with cardiac diagnoses and
IHCA in settings with providers who
have ECMO experience.
TTM: A large randomized trial of
therapeutic hypothermia for children
with IHCA showed no difference in
outcomes whether a period of
moderate therapeutic hypothermia
(32°C to 34°C) or the strict maintenance
of normothermia (36°C to 37.5°C)
was provided.
Use of Advanced Airways During
Pediatric Resuscitation
The effectiveness of the use of
advanced airways in pediatric cardiac
arrest was last reviewed by ILCOR,
the AHA and Heart & Stroke pediatric
experts in 2010. This 2019 review sought
to analyze the evidence associated with
bag-mask ventilation, endotracheal
intubation, and the use of the supraglot-
tic airway. The most recent evidence
is largely derived from observational
studies (ie, registry data) involving only
OHCA.
2019 (Updated): Bag-mask ventilation
is reasonable compared with advanced
airway interventions (endotracheal
intubation or supraglottic airway) in the
management of children during cardiac
arrest in the out-of-hospital setting.
2019 (New): We cannot make a
recommendation for or against the use
of an advanced airway for in-hospital
cardiac arrest management. In addition,
no recommendation can be made about
which advanced airway intervention is
superior in either out-of-hospital or in-
hospital cardiac arrest.
2010 (Old): In the prehospital setting
it is reasonable to ventilate and
oxygenate infants and children with a
bag-mask device, especially if transport
time is short.
Why: With proper experience and
training, the use of bag-mask ventilation
is a reasonable alternative to an
advanced airway strategy (including
endotracheal intubation or use of
supraglottic devices) because the
use of advanced airways may require
more specific training and equipment.
However, if bag-mask ventilation
is ineffective despite appropriate
optimization, the use of advanced airway
interventions should be considered.
Extracorporeal CPR
If ECMO is used as a rescue therapy
when conventional CPR fails, it is
referred to as extracorporeal CPR (or
ECPR). The writing group reviewed
in-hospital registry data about outcomes
from ECPR. These data were derived
predominantly from infants and children
who developed cardiac arrest after
surgery for congenital heart defects.
2019 (Updated): Extracorporeal CPR
may be considered for pediatric patients
with cardiac diagnoses who have
in-hospital cardiac arrest in settings
with existing extracorporeal membrane
oxygenation protocols, expertise, and
equipment.
2019 (Updated): There is insufficient
evidence to recommend for or against
the use of extracorporeal CPR for
pediatric patients experiencing out-of-
hospital cardiac arrest or for pediatric
patients with noncardiac disease
experiencing in-hospital cardiac arrest
refractory to conventional CPR.
2015 (Old): ECPR may be considered
for pediatric patients with cardiac
diagnoses who have IHCA in settings
with existing ECMO protocols, expertise,
and equipment.
Why: Data from large multicentre
registries and retrospective propensity-
scored analyses suggest that ECPR
may provide a survival benefit when
used for refractory cardiac arrest.
However, most data are derived from
young infants with cardiac diagnoses
who develop IHCA. As a result, the
recommendation addresses that patient
population and continues to include the
caveat that ECPR is a resource-intense,
multidisciplinary therapy that requires
appropriate protocols, expertise, and
equipment.
Targeted Temperature
Management
TTM refers to the continuous mainte-
nance of patient temperature within a
narrowly prescribed range. This pediatric
review was triggered by the publication
of the results of the THAPCA-IH trial
(Therapeutic Hypothermia After
Pediatric Cardiac Arrest In-Hospital),
an RCT of TTM 32°C to 34°C vs
TTM 36°C to 37.5°C for children who
remained comatose after IHCA. The
writing group re-evaluated the evidence
of the effectiveness of TTM for both
IHCA and OHCA.
2019 (Updated): Continuous
measurement of core temperature
during targeted temperature
management is recommended.
2019 (Updated): For infants and
children between 24 hours and 18 years
of age who remain comatose after out-
of-hospital or in-hospital cardiac arrest,
it is reasonable to use either targeted
temperature management 32°C to
34°C followed by targeted temperature
management 36°C to 37.5°C or to use
targeted temperature management
36°C to 37.5°C.
2019 (New): There is insufficient
evidence to support a recommendation
about treatment duration. The THAPCA
trials (Therapeutic Hypothermia After
Pediatric Cardiac Arrest) used 2 days
of targeted temperature management
32°C to 34°C followed by 3 days of
targeted temperature management 36°C
to 37.5°C or used 5 days of targeted
temperature management 36°C to
37.5°C.
2015 (Old): For infants and children
remaining comatose in the first
several days after cardiac arrest (in-
hospital or out-of-hospital), continuous
measurement of temperature during
this time period is recommended. Fever
(temperature 38°C or higher) should be
aggressively treated after ROSC.
2015 (Old): For infants and children
remaining comatose after OHCA, it is
reasonable either to maintain 5 days
of continuous normothermia (36°C to
37.5°C) or to maintain 2 days of initial
continuous hypothermia (32°C to
Heart & Stroke Edition 12
34°C) followed by 3 days of continuous
normothermia.
For infants and children remaining
comatose after IHCA, there is insufficient
evidence to recommend cooling over
normothermia.
Why: The publication about a large
multicentre RCT of TTM for children
who remain comatose after IHCA
triggered the 2019 evidence evaluation
and recommendation on the topic
of pediatric post–cardiac arrest
TTM. This in-hospital study, from the
same investigational team and using
the same treatment protocol as the
previously published study of children
after OHCA, compared post–cardiac
arrest TTM 32°C to 34°C with TTM
36°C to 37.5°C. Together, these trials
form the basis of the current guidelines
recommendations.
Fever is common after a hypoxic-
ischemic event such as cardiac
arrest, and registry data have shown
an association between fever and
poor outcomes after cardiac arrest.
The 2019 recommendation allows for
either TTM with moderate hypothermia
or TTM with strict maintenance of
normothermia after cardiac arrest. With
either strategy, monitoring of core body
temperature and the avoidance of fever
are paramount.
Part 13: Neonatal
Resuscitation
Because neonatal cardiac arrest is
predominantly asphyxial, initiation of
ventilation remains the focus of initial
resuscitation. Major topics for evidence
evaluation and the 2019 focused update
to the neonatal resuscitation guidelines
include the following:
• The use of an initial oxygen concentra-
tion of 21% for term and late-preterm
newborns (35 weeks or more of
gestation) receiving respiratory support
at birth remains reasonable. Studies
showing that the use of 100% oxygen
could be harmful prompted the recom-
mendation against its use as the initial
oxygen concentration. This issue was
last reviewed by ILCOR in 2010.
• The initial oxygen concentration to use
for preterm newborns (less than 35
weeks of gestation) receiving respira-
tory support at birth remains 21% to
30% with subsequent oxygen titration
based on oxygen saturation targets.
Administration of Oxygen to
Initiate Ventilation Support for
Term or Near-Term Newborns
(35 Weeks or More of Gestation)
Although it is well known that hypoxia
and ischemia can cause organ injury,
even brief exposure to hyperoxia in
newborns is now believed to be harmful.
As a result, it is important to identify the
optimal initial oxygen concentration to
use when providing initial respiratory
support of the newborn, to avoid both
hypoxemia and hyperoxia.
2019 (Updated): In term and late-
preterm newborns (35 weeks or more of
gestation) receiving respiratory support
at birth, the initial use of 21% oxygen is
reasonable.
2019 (Updated): One hundred percent
oxygen should not be used to initiate
resuscitation because it is associated
with excess mortality.
2015 (Old): It is reasonable to initiate
resuscitation with air (21% oxygen at sea
level). Supplementary oxygen may be
administered and titrated to achieve a
preductal saturation approximating the
interquartile range measured in healthy
term infants after vaginal birth at sea
level.
Why: The ILCOR systematic review
and meta-analysis of 10 original studies
and 2 follow-up studies confirmed a
significant reduction in the critically
important outcome of short-term
mortality—without statistically significant
differences in short- and long-term
neurologic outcomes—with the use
of 21% oxygen compared with 100%
oxygen for term and late-preterm
newborns receiving respiratory support
at birth. It was estimated that 46/1000
fewer babies died when respiratory
support at birth was started with 21%
oxygen instead of 100% oxygen. This
evidence of higher mortality with the
initial use of 100% oxygen resulted in the
Class 3: Harm recommendation against
use of 100% oxygen when initiating
respiratory support for the term or late-
preterm newborn.
Although evidence is still lacking
about the optimal methods of oxygen
titration to achieve oxygen saturation
targets, the use of preductal oxygen
saturation targeting that approximates
the interquartile range measured in
healthy term infants after vaginal birth at
sea level is consistent with the high value
placed on avoiding both hypoxemia and
hyperoxemia.
Many subpopulations of newborns
have not been studied adequately to
determine if they require a different
initial oxygen concentration during
respiratory support at birth. Newborns
with congenital heart disease and other
malformations may be harmed by either
hypoxemia or hyperoxemia, and studies
enrolling these newborns are needed.
Administration of Oxygen to
Initiate Ventilation Support for
Preterm Newborns (Less Than
35 Weeks of Gestation)
Preterm newborns may be even more
susceptible than term neonates to com-
plications of excessive oxygen exposure
(eg, bronchopulmonary dysplasia, ret-
inopathy of prematurity). As a result, it
is important to determine the optimal
oxygen concentration to use for initial
respiratory support, with the need for
titration based on monitored preductal
oxygen saturation.
2019 (Revised): In preterm newborns
(less than 35 weeks of gestation)
receiving respiratory support at birth, it
may be reasonable to begin with 21% to
30% oxygen with subsequent oxygen
titration based on pulse oximetry.
2015 (Old): Resuscitation of preterm
newborns of less than 35 weeks of
gestation should be initiated with low
oxygen (21% to 30%), and the oxygen
concentration should be titrated to
achieve preductal oxygen saturation
approximating the interquartile range
measured in healthy term infants
Heart & Stroke Edition 13
after vaginal birth at sea level. Initiating
resuscitation of preterm newborns with
high oxygen (65% or greater) is not
recommended. This recommendation
reflects a preference for not exposing
preterm newborns to additional oxygen
without data demonstrating a proven
benefit for important outcomes.
Why: New data published since 2015,
including 16 studies (10 randomized
trials, 2 follow-up studies, and 4
observational trials), prompted an
ILCOR systematic review of outcomes of
preterm newborns (less than 35 weeks
of gestation) who received respiratory
support immediately after birth with
the use of low initial oxygen compared
with those who received support with
higher initial oxygen concentration. The
systematic review showed no statistically
significant differences in short-term
mortality or in any of the prespecified
secondary outcomes between the 2
groups. Oxygen saturation targeting,
used as a cointervention in 8 randomized
trials, resulted in nearly all newborns
in the initial 21% group receiving
supplementary oxygen. Many of the
studies were downgraded for possibility
of bias, imprecision, inconsistency, and
small numbers. Many subpopulations
and outcomes have not been adequately
evaluated. Despite these weaknesses
and uncertainty of the evidence, the
recommendation to start with 21% to
30% oxygen with subsequent titration of
supplementary oxygen is based on the
high value of avoiding additional oxygen
exposure to this vulnerable population
without evidence of benefit for critical or
important outcomes.
Part 15: First Aid
The 2019 American Heart Association
and American Red Cross focused update
to the first aid guidelines reaffirms goals
to reduce morbidity and mortality by
Table 2. Typical Signs and Symptoms of Presyncope
Typical symptoms of presyncope
Typical signs of presyncope
alleviating suffering, preventing further
illness or injury, and promoting recovery.
First aid can be initiated by anyone and
supports the Chain of Survival.
The 2019 topic addressed by the First
Aid Task Force is first aid treatment of
presyncope.
Treatment of Presyncope
Presyncope, with recognizable signs
and symptoms preceding loss of con-
sciousness, can last for a few seconds
before onset of vasovagal and ortho-
static syncope. Associated signs and
symptoms include pallor, sweating,
light-headedness, visual changes, and
weakness (Table 2). Presyncope is a
period during which rapid first aid in-
tervention can improve symptoms or
prevent syncope from occurring.
Physical counterpressure manoeuvres
include contraction of muscles in the
upper or lower body (or both) to elevate
blood pressure and alleviate symptoms of
presyncope. Examples of these physical
counterpressure manoeuvres include leg
crossing with muscle tensing, squatting,
arm tensing, isometric handgrip, and
neck flexion. The First Aid Task Force
examined the published evidence about
the effectiveness of these physical
counterpressure manoeuvres for
presyncope of vasovagal or orthostatic
origin.
2019 (New): If a person experiences
signs or symptoms of presyncope
(including pallor, sweating, light-
headedness, visual changes, and
weakness) of vasovagal or orthostatic
origin, the priority for that person is to
maintain or assume a safe position,
such as sitting or lying down. Once the
person is in a safe position, it can be
beneficial for that person to use physical
counterpressure manoeuvres to
avoid syncope.
Faintness, dizziness, nausea, feeling warm/hot or cold, abdominal pain, visual disturbance
(black spots, blurred vision)
Pallor/paleness, sweating, vomiting, shivering, sighing, diminished postural tone, confusion
2019 (New): If a first aid provider
recognizes presyncope of suspected
vasovagal or orthostatic origin in
another individual, it may be reasonable
for the first aid provider to encourage
that person to perform physical
counterpressure manoeuvres until
symptoms resolve or syncope occurs.
If no improvement occurs within 1 to
2 minutes, or if symptoms worsen or
reoccur, providers should initiate a call for
additional help.
2019 (New): If there are no extenuating
circumstances, lower-body physical
counterpressure manoeuvres are
preferable to upper-body and abdominal
physical counterpressure manoeuvres.
2019 (New): The use of physical
counterpressure manoeuvres is not
suggested when symptoms of a heart
attack or stroke accompany presyncope.
Previous: No previous recommendation
addressed the treatment of presyncope.
Why: Physical counterpressure
manoeuvres are simple manoeuvres that
can reduce syncope and its associated
consequences (eg, falls, crashes). As
with other first aid care, the priority for
safety leads the actions of the individual
and first aid provider. Although the
available evidence favors lower body over
upper body physical counterpressure
manoeuvres, many methods and even
a combination of methods can be
beneficial. The evidence suggests that
people prone to vasovagal or orthostatic
syncope can have improved quality
of life by learning and using physical
counterpressure manoeuvres.
Heart & Stroke Edition 14
Summary
The 2019 focused updates to the AHA Guidelines for CPR and ECC include summaries of evidence reviews and revised
recommendations for 11 topics, ranging from DA-CPR and CACs after adult OHCA; advanced airways, vasopressors, and
ECPR for ACLS; DA-CPR for pediatric OHCA; advanced airways and ECPR for pediatric cardiac arrest and TTM for pediatric
post–cardiac arrest care; and initial oxygen concentration for respiratory support of term or near-term newborns and for preterm
newborns. The 2019 American Heart Association and American Red Cross focused update for first aid guidelines includes
evidence summaries and new recommendations for interventions for presyncope. These focused updates serve to revise specific
parts of previous AHA guidelines for CPR and ECC and American Heart Association and American Red Cross guidelines for
first aid. Readers are encouraged to review the complete 2019 focused updates, the published 2019 CoSTR summary, and the
2018-2019 online draft CoSTRs for summaries of the published evidence and for detailed insights and analysis from the expert
ILCOR and AHA writing groups.

Recommended Reading
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Force. Pediatric targeted temperature management post cardiac arrest: consensus on science with treatment recommendations.
International Liaison Committee on Resuscitation website. costr.ilcor.org. Accessed July 8, 2019.

Buick JE, Wallner C, Aickin R, et al; for the International Liaison Committee on Resuscitation Pediatric Life Support Task
Force. Pediatric targeted temperature management post cardiac arrest: a systematic review with meta-analysis. Resuscitation.
2019;139:65-75.

Charlton NP, Pellegrino JL, Kule A, et al. 2019 American Heart Association and American Red Cross focused update for first
aid: presyncope: an update to the American Heart Association and American Red Cross guidelines for first aid [published online
November 14, 2019]. Circulation. doi: 10.1161/CIR.0000000000000730

Donnino MW, Andersen LW, Deakin CD, et al. Extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest—adults:
consensus on science with treatment recommendations. International Liaison Committee on Resuscitation website. costr.ilcor.org.
Accessed May 22, 2019.

Duff JP, Topjian A, Berg MD, et al. 2019 American Heart Association focused update on pediatric advanced life support: an update
to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [published
online November 14, 2019]. Circulation. doi: 10.1161/CIR.0000000000000731

Duff JP, Topjian A, Berg MD, et al. 2019 American Heart Association focused update on pediatric basic life support: an update to
the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [published online
November 14, 2019]. Circulation. doi: 10.1161/CIR.0000000000000736

Escobedo MB, Aziz K, Kapadia VS, et al. 2019 American Heart Association focused update on neonatal resuscitation: an update to
the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care [published online
November 14, 2019]. Circulation. doi: 10.1161/CIR.0000000000000729

Granfeldt A, Avis SR, Nicholson TC, et al; for the Advanced Life Support Task Force of the International Liaison Committee on
Resuscitation. Advanced airway management during adult cardiac arrest: a systematic review. Resuscitation. 2019;139:133-143.

Guerguerian AM, de Caen AR, Aickin RP, et al. Extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest—pediatrics:
consensus on science with treatment recommendations. International Liaison Committee on Resuscitation website. costr.ilcor.org.
Accessed May 22, 2019.

Holmberg MJ, Geri G, Wiberg S, et al; for the International Liaison Committee on Resuscitation’s (ILCOR) Advanced Life Support
and Pediatric Task Forces. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: a systematic review. Resuscitation.
2018;131:91-100.

Holmberg MJ, Issa MS, Moskowitz A, et al; for the Advanced Life Support Task Force of the International Liaison Committee on
Resuscitation. Vasopressors during adult cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2019;139:106-121.

Isayama T, Dawson JA, Roehr CC, et al. Initial oxygen concentration for term neonatal resuscitation: consensus on science with
treatment recommendations. International Liaison Committee on Resuscitation website. costr.ilcor.org. Accessed May 22, 2019.

Heart & Stroke Edition 15

Jensen JL, Cassan P, Meyran D, et al; for the International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force and
Pediatric Task Force. First aid interventions for presyncope: consensus on science with treatment recommendations. International
Liaison Committee on Resuscitation website. costr.ilcor.org. Accessed May 22, 2019.

Jensen JL, Ohshimo S, Cassan P, et al. Immediate interventions for presyncope of vasovagal or orthostatic origin: a systematic
review. Prehosp Emerg Care. 2019:1-63.

Lavonas EJ, Ohshimo S, Nation K, et al; for the International Liaison Committee on Resuscitation (ILCOR) Pediatric Life Support
Task Force. Advanced airway interventions for paediatric cardiac arrest: a systematic review and meta-analysis. Resuscitation.
2019;138:114-128.

Nikolaou N, Dainty KN, Couper K, Morley P, Tijssen J, Vaillancourt C; for the International Liaison Committee on Resuscitation’s
(ILCOR) Basic Life Support and Pediatric Task Forces. A systematic review and meta-analysis of the effect of dispatcher-assisted
CPR on outcomes from sudden cardiac arrest in adults and children. Resuscitation. 2019;138:82-105.

Nuthall G, Van de Voorde P, Atkins DL, et al. Advanced airway interventions in pediatric cardiac arrest: consensus on science with
treatment recommendations. International Liaison Committee on Resuscitation website. costr.ilcor.org. Accessed July 8, 2019.

Olasveengen TM, Mancini ME, Vaillancourt C, et al. Emergency care: dispatcher instruction in CPR: consensus on science with
treatment recommendations. International Liaison Committee on Resuscitation website. costr.ilcor.org. Accessed July 12, 2019.

Panchal AR, Berg KM, Cabañas JG, et al. 2019 American Heart Association focused update on systems of care: dispatcher-
assisted cardiopulmonary resuscitation and cardiac arrest center: an update to the American Heart Association guidelines
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Heart & Stroke Edition 16
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